Recovery From Schizophrenia: Psychiatry And Political Economy

160 SCHIZOPHRENIA IN THE THIRD WORLDexistence by self-employment in street-vending and similar activities or with lowand irregular earnings from work in the formal and informal segments of theurban labor market. Outright unemployment, however, is often most severe in theupwardly striving, urban middle classes. In rural areas, this reversal of the usualWestern pattern is even more marked, with unemployment among the aspiringeducated at times being severe, while those working the land are largely outsidethe labor market. 50In rural districts, therefore, we should look for a reversal of the usual Westernpattern of outcome from schizophrenia and for superior outcome in the lesseducated—the subsistence farmers with limited exposure to Western acculturativeforces. A mixed recovery picture might be expected to occur in those urban areaswhere economic development is incomplete and is creating stresses for the newmanagerial and professional classes. In the most highly developed cities of theThird World we should expect a pattern of recovery similar to the West with thebest outcome in the high-status occupations. In general, we might anticipateoutcome to be better in villages, where more of the population is outside thewage-labor market, than in the cities.In fact the WHO data show neither rural nor urban living to be strongpredictors of good outcome. 51 The information on residence, however, wasgathered at intake rather than at follow-up. The lack of association betweenresidence and outcome, therefore, may merely reflect what several authors havenoted—that migrant laborers who fall ill while working in the industrial areasreturn to the village to recuperate. 52 City-dwellers with psychosis may benefitfrom this return to traditional village roles.Other WHO Pilot Study data more clearly document an association betweenoccupation and outcome. Farmers were more likely than patients of any otheroccupation to experience the most benign pattern of illness—full remission withno relapses—and the unemployed were least likely to experience such a mildcourse to the psychosis. In urbanized Cali and Taipei patients from high-statusprofessional and managerial occupations were found to achieve good overalloutcome, while this was not the case in the largely rural catchment area aroundAgra, India. 53 This pattern confirms the impression that schizophrenia may bemore benign in the successful upper classes in the industrialized setting, but moremalignant among the better educated in India who are known to suffer rates ofunemployment several times greater than the poorly educated and illiterate. 54 Thedata from Nigeria do not fit as neatly. Even though many patients in the sampleappear to have come from rural districts, Nigerians with schizophrenia inmanagerial jobs experienced good overall outcome. 55 This could be explained bya strong local demand for educated labor at that time or, again, the high mobilityof the migrant labor force may confuse the picture; patients who were unable tocontinue in managerial positions could return to a less demanding role in theirfarming community.Migrant-labor practices allow people with schizophrenia in the Third World tochange occupation and residence after developing psychotic symptoms. Level of